Healthcare Provider Details

I. General information

NPI: 1033179783
Provider Name (Legal Business Name): DEMETRIUS DENISE HOLIDAY PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2006
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 JESSE HILL JR DR SE
ATLANTA GA
30303-3032
US

IV. Provider business mailing address

1670 JACKSON SQ NW APT/SUITE
ATLANTA GA
30318-0656
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-9916
  • Fax:
Mailing address:
  • Phone: 770-354-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN146949 NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: